Abstract

Although the government and nursing bodies agree that patients have a right to be treated with compassion, reports such as the Health Service Ombudsman’s Care and Compassion? have criticised the NHS, and nurses in particular, for lacking this quality. This article considers how compassion has been characterised by nurse writers and educators throughout the profession’s history and considers what lessons can be learnt by the profession today.

Earlier this year, the Health Service Ombudsman’s (2011)report Care and Compassion? criticised the standards of care for older people. The document described a number of cases, representative of some 9,000 complaints, saying they “present a picture of NHS provision that is failing to respond to the needs of older people with care and compassion”. Two years earlier, the Healthcare Commission reached similar conclusions. It said trusts needed to resolve shortcomings in nursing care - specifically compassion, empathy and communication (Healthcare Commission, 2009). Earlier reports had also expressed concern about a lack of care and compassion in healthcare, particularly towards older people (Health Service Commissioner for England, for Scotland and for Wales, 1998; 1997).

Government and nursing bodies agree patients have a right to be treated with compassion (Prime Minister’s Commission on the Future of Nursing and Midwifery, 2010; Knight et al, 2008). In addition, compassion, care and communication are designated as elements of an “essential skill cluster” by the Nursing and Midwifery Council (2010). The question is: can nurses be taught to be compassionate?

The compassionate character

Historically, developing the “compassionate character” was the impetus for care, and gave the nursing profession its ethos. In Florence Nightingale’s view, good nurses were good people who cultivated certain virtues or qualities in their

character - one of which was compassion. Patients were expected to be the centre of all nurses’ thoughts. Nurses had to always be kind (but never emotional) because they were caring for living people, unlike plumbers or carpenters. As Nightingale reiterated in letters to probationer nurses, it is what the nurse is inside that counts, “the rest is only the outward shell or envelope” (Nightingale, 1873-1897).

From Nightingale’s time until the 1960s, numerous nurse writers championed similar ideas of care. Most textbooks began with an introductory chapter on the moral basis of nursing and the importance of developing a virtuous character. Writers used the same language and approach as Nightingale.

One of the earliest was Florence Lees, who oversaw the care of the wounded in the Franco-Prussian War. She listed the qualities nurses needed to learn in training school, which were cleanliness, neatness, obedience, sobriety, truthfulness, honesty, punctuality, trustworthiness, quickness and orderliness. Nurses also had to be patient, cheerful and kindly (Lees, 1874).

Nurse training was about becoming kind and compassionate, as well as technically competent. Nursing teachers believed that, in order for nurses to be compassionate, they needed to be trained to develop a compassionate character.

Inborn love of nursing

Rachel Williams of St Mary’s Hospital, London, and Alice Fisher of the Fever Hospital, Newcastle upon Tyne, entreated women not to enter nursing simply to earn a living. Nursing had to be about an “inborn love” of the work. Nurses needed “to combine unselfishness and a strong resolution not to be conquered by difficulties” (Williams and Fisher, 1877).

Catherine Wood, the lady superintendent of the Hospital for Sick Children, Great Ormond Street, took a similar view. Nurses were not born but made; they needed to have six qualities, which are outtlined in Box 1. She advocated that nurses must think only of their patients’ comfort, not of themselves, that they should be conscientious and diligent, unseen as well as seen. In 1878, she wrote:

“Gentleness of the heart will teach gentleness to the hand and to the manners. I can give no better rule than to put yourself in your patient’s place.”

Eva Lückes, matron of the London Hospital, argued the personal qualities of the nurse were the absolute basis for nursing. Above all, the “character” of the nurse made the “real” nurse. She believed the indispensable qualities of this vocation were: self-discipline, personal responsibility for learning, truthfulness, obedience, punctuality, loyalty and the kindliness of genuine compassion (Lückes, 1886).

EJR Landale taught that nurses needed certain qualities - quietness, presence of mind, gentleness, accuracy, punctuality, memory, observation, forethought, promptness, unselfconsciousness, obedience, kindness and courtesy. Service before self was the only motivation suitable for the nurse. To escape the monotony of a narrow home life, to earn a living or raise social status were unacceptable reasons for taking on the role (Landale, 1893).

Similarly, at the turn of the 20th century, Mary Annesley Voysey considered the nurse’s qualities and motivations, concluding that nurses needed to be “…obedient, truthful, conscientious, careful, kind and faithful, and work without looking for results” (Voysey, 1905).

Development of virtue

MN Oxford, a sister at Guy’s Hospital, stressed the importance of virtuous qualities in her nursing textbook. Nurses should be temperate, sober, careful, clean and busy, and in behaviour “virtuous, loving, diligent” (Oxford, 1900). This was also the view of E Margaret Fox, matron of the Prince of Wales’s Hospital in north London’s Tottenham. Character was more important than cleverness; attributes such as reverence, gentleness, discretion and uprightness needed to be cultivated for the wellbeing of patients (Fox, 1914).

This teaching on the development of virtue was also evident in the writings of A Millicent Ashdown, a lecturer in bandaging and practical work at King’s College, London, and former examiner to the General Nursing Council. Ashdown suggested nurses’ main qualifications be a “real love” for attending to the sick and helpless, a strong constitution and an equable temperament. Discipline, obedience, loyalty, generosity, tenderness, gentleness and cheerfulness were the basis of her work:

“[Nurses] must look upon their patients as individuals to be cared for personally, not merely as ‘cases’ to be treated medically” (Ashdown, 1917).

M Vivian, former matron of Victoria Hospital in Deal and Princess Christian Hospital in Weymouth, reiterated these same values and stated that the hardships nursing involved - overwork and underpay - and the lessons of self-denial formed a nurse’s character and methods of thought. This formed the “rule of life”, which gave them the highest possible ideals and standard of work (Vivian, 1920).

E Maude Smith, former matron and superintendent of nurses at Withington Hospital in Manchester and examiner for the General Nursing Council, reminded nurses they could not be a good nurse without being a good woman (Smith, 1929).

A year later, the matron of Charing Cross Hospital, Mary Cochrane, wrote that, despite changes in nursing brought on by the First World War, “many restrictions and apparent hardships are abolished, but the profession still calls for high principles and courage; in fact, all the essentials, which went to make the first nurse” (Cochrane, 1930).

Modern age of nursing

As the modern age of nursing approached and biomedical nursing knowledge progressed, the profession’s ethical foundation remained. Esther Fisher, matron of New End Hospital, in London’s Hampstead, described nursing as “a sacred calling” - its purpose being to alleviate the sufferings of humanity - and so not to be taken up lightly. For this reason, the qualities of the nurse were extremely important (Fisher, 1937).

Evelyn Pearce, a former senior nursing tutor at the Middlesex Hospital and a member of the General Nursing Council, reiterated this vision in her textbook and continued to do so in subsequent editions. She saw nursing as evolving technically while maintaining the Nightingale tradition:

“The present generation of nurses has grown up entirely in the technological age of this century. The modern nurse, like the modern doctor, is the product of an evolutionary process, but one where, nevertheless, her compassionate approach to patients remains unchanged” (Pearce, 1937-1971).

In a later edition, Pearce developed her teaching:

“Character is what we make of ourselves through the acquisition of moral virtues - the ‘cardinal virtues’ of prudence, justice, temperance and fortitude.”

Compassionate care is not expressed so much in words but in actions, such as a firm touch, gentle and courteous manner and kindness. In 1969 she explained that:

“Kindness cannot be overestimated. It endows the character with qualities which make it rich and warm as the sentiments of the heart temper the efficiency of the work of head and hands.”

Margaret Houghton began her textbook with a history of nursing as a vocation and described the qualities of character and mind nurses had to develop or acquire during training. These included kindliness, sympathy and a cheerful and pleasant manner towards patients to relieve their anxiety and encourage confidence (Houghton, 1938).

Similar views were expressed in 1950 by two sister tutors from Guy’s Hospital, Hilda Gration and Dorothy Holland, who were both General Nursing Council examiners. While they agreed patterns of nursing had changed from old traditions of nursing, which rested on nurses being utterly devoted to the profession, they argued they must not lose their idealism or need for self-discipline. Training started and should continue at the bedside, they asserted. Patterns changed but virtues did not. Nurses absorbed these values through examples of others’ daily practices. The good nurse was the kind nurse who took pleasure in spending time with patients and developed relationships with them.

Lillian Darnell, secretary of the Nursing Recruitment Service at King Edward’s Hospital Fund, suggested Nightingale’s list of the qualities required of a good nurse could not be bettered (Darnell, 1959). Winifred Hector, principal tutor of St Bartholomew’s Hospital, wrote that nurses needed not only mental and physical health, but also reserves of spiritual strength as the foundation for their work (Hector, 1960).

For a century, nurse writers thought compassion was an essential virtue to be developed by nurses to cope with the discipline, hardship and stress associated with nursing life. This was part of training and fundamental to the apprenticeship model. Compassion was a quality of character in nature to be nurtured by training.

Jarvis, an educationalist, rather than a nurse, referred to this historical approach to nurse training as a “process of induction”. Nurse educators were guardians of a tradition about the meaning of nursing. This involved the education of character, and the character of the nurse was as important as the knowledge she or he possessed (Jarvis, 1996).

Conclusion

Throughout nursing history, compassion has been viewed as a quality associated with an individual’s character. Compassion stems from virtue. It is about the intent and practised disposition of the nurse. It is nurtured in, and by, the culture and ethos of clinical practice.

Compassion is not strained by pressure or displaced by stress. The greater the hardship, the more compassion is required. Genuine compassionate care is not a quantifiable skill, an assumed technique or an emotion or feeling. It is the humane quality of kindness.

5 key points

Government and nursing bodies agree patients have a right to be treated with compassion

Historically, developing a “compassionate character” was the impetus for care, and gave the nursing profession its ethos

Throughout nursing history, compassion has been viewed as a quality associated with an individual’s character

Compassion is about the intent and practised disposition of the nurse

Genuine compassionate care is not a quantifiable skill, an assumed technique or an emotion or feeling - it is the humane quality of kindness

Lückes ECE (1886) Hospital Sisters and their Duties. London: J and A Churchill.

Nightingale F (1873-1897) Letters and Addresses

to the Probationer Nurses in the “Nightingale Fund” School at St Thomas’s Hospital and Nurses who were Formerly Trained There. Original Letters and Prints for Private Circulation. Letters dated 1873, 1874, 1888. London: University College Library Holdings.